Archive for the 'Geriatrics' Category

Alert the media that for the coming week, everyone will be DNR/DNI until proven otherwise, instead of full code.

Miraculously watch as everyone rapidly develops a living will, durable power of attorney, and talks about their wishes with their loved ones.

You would’ve thought the Terry Schaivo thing would’ve done this already, but I seem to get all the patients who have no idea what they want. Just last night, an elderly Hispanic man was admitted for possible heart failure and possible heart attack, and after a lengthy discussion about code status, he tried to give me this innocent little indecisive giggle-shrug-smirk, as if I asked him what type of food he wanted to eat for dinner and just wanted to be agreeable. This ain’t one of those types of questions. You need an answer.

On a more ethical but medically ethical topic, some people propose making the organ donor system an opt-out system, where one would automatically be consenting to donate their organs unless they specifically said they didn’t want to.

*A person’s code status tells the health care system what he or she would like done if their heart stops or lungs stop working–would they like everything done (full code) at one extreme, or would they like no measures taken (DNR, DNI – do not resuscitate, do not intubate). You can pick any level of code status, and have specific parameters as well.

I really, really enjoyed Geriatrics. And since medicine is going to practically turn in to geriatrics in a few years when our parents (and maybe you) get older, there are a number of really important things to remember about our elderly loved ones:

“Elderly.” “Geriatric.” There’s not an age where you become “elderly,” or that you’re “allowed” to see a geriatrician. It’s usually designated as 65, just because that’s when Medicare kicks in, but often it’s a functional status–what can the person do, and what does he or she need assistance doing?

Falls. Older patients more likely to fall, and their falls are much more dangerous. They are more likely to pass out or faint, because they have less fluid reserves in their bodies, and are often on multiple medications, many of which can cause light-headedness. They also often have less muscle mass, or are in worse shape, or have arthritis making them less steady on their feet. Diabetics can lose nerve sensation, especially in their feet–this includes the nerve sensations that tell their brains where their feet actually are in relation to their legs. And since older folks tend to have more osteoporosis (brittle bones), they’re more likely to break hips, break other bones, rupture veins in their heads, too. Continuing the logic, elderly people are slower to heal and recover, so they have longer hospital stays, more likely to get infections, and more likely to do worse. So we want to keep elderly folks healthy and out of the hospital!

Incontinence (losing control of your bladder or bowels) is common in the elderly, too–but often can be fixed or improved with medications.

It’s important to talk about advanced directives with older patients, or durable powers of attorney; this lets doctors, nurses, family members, and friends know what the patient wanted done, and what he or she didn’t want done. This respects the patient’s wishes to the best of our ability, and allows family and friends to have one less thing on their mind during a serious illness or terminal illness.

Depression is common in the elderly, and can present differently in the elderly than in younger patients. Symptoms can be memory problems, thinking problems, fatigue, loss of interests–which can sometimes be confused with dementia (like Alzheimer’s disease). Isolation can also be a problem–when people lose their loved ones they’ve depended on their entire lives, they may not want to meet new people or leave the house.

Functioning: it’s important for physicians to try to get a sense of what an older patient can and cannot do. These are known as ADLs (activities of daily living) and include dressing, feeding, showering, toileting, etc. Instrumental ADLs are other activities that are important for daily functioning in our society–going shopping, balancing a checkbook, doing the cleaning, cooking, etc.

Great noon-time talk today about prognosis and predicting outlook for terminal diseases (until about the last 72 hours). Summary, from a palliative care and Hospice doc: Medicine is still terrible at predicting how much time any one individual has left. We can say “Most people with your condition and your status will live this long,” but it creates a ton of anxiety for physicians if they’re asked for a specific number, because it’s totally worthless. I thought her analogy would be helpful in explaining this to patients.

It’s like weather versus climate. I can tell Californians that it’s probably going be sunny there, and I can tell Alaskans it’s probably going to be cold there, but if you ask me to tell a particular town on a particular date what the weather’s going to be, I might as well just pull it out of a hat. Until it gets very close to that date, I really can’t say if it’s going to rain or going to be sunny.

Her last list was really touching and rang true. The 5 Things All Patients Want to Tell Their Loved Ones Before They Die:

The powers that be (or, if you prefer, the Power that be’s) have a funny sense of humor. Take medical student who thinks feet are totally disgusting, and sign him right up for Podiatry clinic. Ambulatory Medicine clerkship, we are not getting off … on the right foot. (Pun intended.)

Last month, on Geriatrics, I had a diabetic patient in clinic, so I took off his socks, only to have little flakes of foot skin (eczema? xerosis?) fly up into the air and be inhaled by yours truly. From now on, I’m just asking the patients to take their own damn foot apparel off.

It always just amazes me that there’s so much variety in the human experience. That you and I can be so genetically similar, and yet have such different backgrounds and understandings of the world. I saw a professional today in clinic for high blood pressure, and as I was going through my laundry list of questions, I found a pertinent positive:

And he didn’t bat an eye. I followed up skeptically: “Night sweats that soak through your t-shirt?” And again, not batting an eye, “Yeah, soaked every 3-4 days.” Taking his perspective, I guess it doesn’t seem that strange–he’s just sweating a lot at night. Maybe due to a nightmare or something. But I instantly took my own perspective–at the first sign of night sweats like that, I’d get to a doctor! (You’re probably wondering, I’d imagine. Night sweats, coughing up blood, and weight loss are the “classic” findings in a patient with tuberculosis.)

Sometimes you forget not everyone has all this information and experience. You use your medical knowledge so frequently, and the medical associations and logic become so commonplace to your brain that you start to feel like they’re as elementary and commonly-learned as addition, the state capitals, or Shakespeare. “They have temporal arteritis? Well of course they’re having vision changes. Duh! Next you’re going to tell me you didn’t know Dorothy was from Kansas!”

So we’re placing a PPD (TB skin test). Another possible point for my diagnosis pickup. Cha-ching!

Attention all clinical folks: there’s a reason you always at least listen to the heart and lungs. (I previously thought this was just a cruel med student joke.)

Guy comes in, typical geriatric patient with multiple chronic diseases, and I notice that he’s huffing and puffing, walking about the 30 feet from the waiting room to the exam room. I comment about this, and he and his wife note that he’s had this over the past month, but never before. Curious.

We talk through the rest of the visit, talking about his memory problems (dementia), his recent falling 20-30 times per week, his getting-up-to-pee 5-6 times per night, his chronic 10/10 lower back pain, and then I do the physical exam. Rales (also known as crackles) on both sides of the bottoms of his lungs. Pitting edema in his ankles. Curious indeed.

So I’m presenting to the attending and fellow, and they’re blown away. “Wow! Great job! Good pickup!” So we order an echo, get an EKG in the clinic, and put in an urgent cardiology request.

I saw an elderly Russian woman in clinic two weeks ago, and through the translator, she asked me, “Why are you asking me all these questions? I’ll die when I die. You can’t fix old.”

I told her that she was right; we can’t fix old, but we can try to address disease. Many people confuse the two, assuming that getting old just comes with certain diseases, like urinary incontinence. It’s not true. Older people are more likely to have hearing loss and worse vision, but some things aren’t so much a product of aging as they are more common in the elderly population.

Polypharmacy is the taking of multiple medications for multiple medical problems. My winning patient so far had 24 when I saw him in clinic on Wednesday. If anyone honestly thinks that patients are taking all of those medications, with all of their different schedules (two of this one in the morning, 1 at night; 3 of this one every 8 hours; one-half tab of that other one every day), they’ve got to be kidding themselves. How many of us can reliably even take a course of antibiotics for 10 days?

Prevention is the only solution, people. Eat better, exercise more, stop smoking, and wash your hands. That’ll lead you to a healthier life than any pill.

I’ve been on service a week, and I’ve already seen quite a range of presentations and stages of Alzheimer’s. I had no idea there was such variety.

The first patient, diagnosed at the young age of 57, had deteriorated rapidly. She was very aphasic–meaning she couldn’t find the words she wanted, nor could she understand some of the things I asked. She scored a 3/30 on the MMSE, a quick test of one’s cognitive functions. This is very poor. Often I would ask a question, and she would respond with “Well, I… you know, I am… and so, it is, because, you know, it… is. And it’s okay, because what it is… is.” It was very difficult emotionally to continue; I felt really uncomfortable asking her more questions. This was complicated by the fact that her partner was in the room, a psychiatrist. He looked like he was on the verge of tears with every question I asked. I asked him how he was doing, if he might like some help caring for his wife, but he said he was fine.

On the exact flip side, I met another woman who has Alzheimer’s and was very happy-go-lucky. Maybe her disease had just progressed less. She still recognized her children, but didn’t know much else. Besides that, she seemed content. When I asked her the year, she smiled and replied, “Oh, I don’t keep up with that.” What an outlook. Her children, who were at the appointment with her, seemed to have accept their mother’s illness. They smiled and joked with their mother, and tried to make the best of the situation.

An idea for a meme that the medbloggers could start: bloggers posting their wishes/advanced directives/durable powers of attorney. As with the Terry Schaivo mess, everyone was talking about people writing out (or discussing) their wishes with loved ones. With a simple blog entry, a person could provide a written document of their wishes. There’s 5 million bloggers out there, maybe it’d help?

Medbloggers could draft a template, define terms, and explain some possible scenarios, and then people could copy->paste and link to other people’s? Whatchya think? (I realize a durable power of attorney form would be more useful, but this could be a start?)

People post their five favorite songs, or favorite book, or favorite quote, why not something a little deeper? (They could password-protect the entry if they felt that it was too private for the general public.)

Man. I forgot how nice it is to actually see human beings patients again. Staring at films and CTs and MRIs (oh my!) made me forget that there’s actual people that surround those images, not just bone structures, opacities, densities, consolidations, and strictures. We started out today at a local nursing home, rounding on some patients. Kind of wish I had already had my Medicine clerkship, but I’m usually a quick learner.

Depending on the patient, sometimes the surgical service will send a patient to the nursing home for long-term recovery, and it just so happened that I got to see a surgical patient from many months ago at the nursing home. It was definitely some delayed continuity of care, and he had no idea who I was, but it was great to see the spectrum and time-course of healing.

The great thing, I’m hoping, about this rotation, is its variety. We rotate through a nursing home, an inpatient ward, a hospice unit, a palliation clinic, a geriatrics clinic, hypertension clinic, and andrology clinic, as well as attend Internal Medicine conferences, so I get exposure to a lot of different geriatric sub-specialties.

Today we had an inservice from the hospice chaplain discussing how to take a spiritual history, how to understand some of the spiritual/religious concerns of the dying or elderly patient, and some advice on how to answer patients’ questions that are religious in nature. (I’ll be the first one to admit that I’m struggling right now with figuring out my own spirituality and belief system, with my interests in religion and spirituality a seemingly distant memory from college.) I’d feel much more comfortable dealing with patients’ questions about living and dying and the Unknown and God (or god(s)) than questions directed toward my personal belief system (I get a knee-jerk reaction to questions like, “Do you believe in Jesus,” or “Have you found Christ,” mostly because of obsessively-persistent Christians from my undergrad). As one of my residents pointed out, however, most often questions like these are efforts by the patient to feel out the physician–to see if the physician is “safe” to talk with about spiritual matters. It’s actually probably pretty similar to how LGBT folk try to feel out someone to see if they’re LGBT-friendly before opening up.

I couldn’t help but compare this service to Neurology and Surgery, and initially feel like the others were leaving out this spiritual component. I can see how in some cases, it’s probably a back burner topic: people want their gall bladder out, not a discussion of the Universe. (Or maybe they do?) Or perhaps it’s just that there’s not time on those other services to discuss these matters? At the least, however, I would think asking one or two questions about it (“Do you have any spiritual beliefs you would like to be respected during your care?”) might be useful, especially in cancer surgery or terminal illnesses.

On to clinic, where I saw one patient, an elderly, World War II veteran who had just turned 95. He has terminal cancer, but refused treatment, and two years later, still has no symptoms from it. We caught a previously undiagnosed problem with incontinence, but otherwise he was in reasonably good health for his age and condition. He said he didn’t fear death; he’d been a rifleman in the War and noted that “If you worried about dying while you were out there, it didn’t do you any good.” Kind of a privelege that I have the time to worry about death at all.

If anything, I can tell that this will be a month of lots of thinking about ethics, living, dying, and Life in General. Good for the soul.